_ PRIVACY ACT MATERIAL REMOVED — GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name , Sex — fe Age /3 Residence: 1954-1960 — grRICP 1960-1966 _LAsyr 1966-1972 — 197 2- _ Lt KieP LYAPERD Short description of symptoms: (Surlle, trae) hiadhaeber, Sarang “tot, effets Surgery — cate , pa CLs pro a & Vat - Gut baey beer rLinwerZy Mor js* (Bet fe,t del)vear - Have you been receiving treatment for any illness for a period over one year? ye 7 Has anyone in your family complained of similar symptoms to the ones you are now experiencing? Ko surgery? Maw — Signature_ 5011854 | “pate rf /9 / fo? PRIVACY ACT MATERIAL REMOVED